Comprehensive Healthcare Inspection of the Gulf Coast Veterans Health Care System in Biloxi, Mississippi

Report Information

Issue Date
Report Number
22-00074-218
VISN
1
State
Alabama
Florida
Mississippi
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Major Management Challenges
Benefits for Veterans
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (emergency department and urgent care center suicide prevention initiatives) The OIG issued six recommendations for improvement in three areas: 1. Quality, Safety, and Value • Defined governance structure 2. Medical Staff Privileging • Ongoing Professional Practice Evaluations o Service-specific criteria o Data maintained in privileging folders • Evaluations by practitioners with equivalent specialized training and similar privileges • Executive Committee of the Medical Staff review 3. Environment of Care • Clean and safe environment

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders follow their defined governance structure.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff determines any additional reasons for noncompliance and ensures leaders use service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff determines any additional reasons for noncompliance and ensures service chiefs maintain Ongoing Professional Practice Evaluation data in licensed independent practitioners’ privileging folders.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff reviews the service chiefs’ recommendations along with clinical competence information when making privileging recommendations for licensed independent practitioners.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The System Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.